A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Evaluate the firmness of the uterus (fundus).

Obtain a type and crossmatch.

Administer oxytocin infusion.

Initiate oxygen therapy by nonrebreather mask.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

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Correct Answer is A

Explanation

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

A. Focus on the family unit and its members. B. Expressions of excitement. C. Eagerness to learn newborn care skills. D. Lack of appetite.

Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

Focus on the family unit and its members is more characteristic of the “letting-go” phase.

Choice B rationale:

Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.

Choice C rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.

Choice D rationale:

Lack of appetite is not a typical characteristic of the dependent, taking in phase.

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A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a postpartum woman.Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.